Harmonizing vaccine and infrastructure development to tame cholera outbreaks across Africa

Vaccines and clean water shortages continue to give rise to cholera outbreaks in Africa. Coordinated efforts to increase vaccine distribution and improve physical infrastructure are needed while considering future outbreaks and water demands due to conflicts and climate events.

An efficient two-dose oral cholera vaccination regimen exists, providing immunity for about three years, but a global vaccine scarcity has compounded the situation 3 .These shortages are not only the result of a global increase in cholera cases but also of vaccine producers' collective lack of interest in producing cholera vaccines.The oral cholera vaccine is inexpensive and requires production at large sales to create profit, which suggests that the vaccine may be of little financial interest to most enterprises in high-income countries.The consequent vaccine scarcity prompted the International Coordinating Group (ICG) on Vaccine Provision to abandon the conventional two-dose cholera vaccine protocol in favor of a single dosage to assure greater coverage 4 .The reduced dose of the cholera vaccine is a temporary solution since results show identical efficacy in the first year and lesser effectiveness over the first four years after immunizations compared to normal vaccine doses 5 .
Gavi reported that 48 million vaccination doses were utilized in 2022 and 2023, 10 million more than the previous decade 6 .The vaccine shortage will be exacerbated by a manufacturing decision to discontinue production of the Shanchol vaccine, one of just two cholera vaccines accessible for large humanitarian efforts.WHO recommends cholera vaccination for emergency and relief workers likely to be exposed to cholera patients or contaminated food or water, as well as the special population, including HIV-infected individuals, Pregnant women, and populations in closed institutions 3 .
Similar to the shortage of vaccines, Africa has been going through a water crisis primarily due to water scarcity, lack of adequate water and wastewater infrastructure, and improper water management and governance 7 .Half of all countries on the continent scored very low on having basic water infrastructure 7 .Three of every five people on the continent do not have access to safe drinking water, and three of every four lack access to enough sanitation and hygiene services 8 .These conditions are further exacerbated by changing weather patterns, climate change, and phenomena such as El Niño leading to floods and droughts.The floods in late 2023 in eastern Africa destroyed thousands of homes, and nearly two million people were forced to relocate to temporary shelters with crowded and unsanitary living conditions, which may increase the spread of disease 9 .
Another major obstacle in confronting such outbreaks is armed conflicts.Conflicts exhaust response capacities, healthcare infrastructure, and material and financial ability to provide sufficient treatment and prophylactic measures.In the Democratic Republic of the Congo, a key epicenter of the current outbreak, cases are concentrated in the conflict-torn east, where entire communities have been razed to the ground, and floods and landslides have occurred 10 .Years of ongoing multidimensional violence have resulted in huge population displacement (up to 7 million) 11 , reducing Congolese citizens' resilience to such outbreaks.When compounded with natural hazards and extreme events, large and long-lasting epidemics present extra challenges for healthcare systems, including damage to physical infrastructure, shortage in supplies, and reduced availability of personnel, who are already overburdened by responding to various diseases in challenging conditions 10,12 .

Infrastructure improvement and vaccine access recommendations
The Global Task Force on Cholera Control has set goals to cut cholera mortality by 90% and eradicate cholera in up to 20 countries by 2030.These targets necessitate investments in safe water and sanitation infrastructure for all.Capacity must also be built for preventative, readiness, and preparedness operations, such as simplifying the supply chain for critical diagnostics.Vaccine manufacturing must be increased globally and in severely afflicted areas, including many regions in Africa.Even though Ghana has demonstrated that it is possible to decentralize and increase sustainable vaccine production in Africa, becoming the continent's first manufacturer of a cholera vaccine 13 , the continent provides less than 1% of the vaccines it uses.
While vaccine production is important in reducing the spread of cholera, the lack of basic water infrastructure to produce safe and clean drinking water and the continued struggle to achieve basic hygiene services make any progress toward vaccine development rather irrelevant.In 2022, UNICEF reported that a 12-fold increase in current rates of progress on safely managed drinking water, a 20-fold increase for safely managed sanitation, and a 42-fold increase for basic hygiene services are needed to achieve the Sustainable Development Goal targets in Africa 14 .Therefore, substantial investments are needed to provide clean water, basic sanitation, and hygiene.While water governance and management are key considerations, developing basic water infrastructure is a prerequisite to ensure accessibility to clean drinking water.
Partnerships and capital investment are urgently required throughout African countries to tackle vaccination and clean water shortages.Integrating vaccine distribution with water infrastructure development is critical for cholera prevention.Priority should be given to analyzing and correcting water infrastructure inadequacies in areas with high cholera rates and inadequate vaccination access.It is critical to establish community-run water purification centers that can also serve as vaccination locations.Climate change and population expansion must be taken into account while addressing water constraints.Agreements that encourage water diplomacy and resource sharing across the continent are critical.Furthermore, it is vital to take care of the entire water supply chain, from source to consumption for effective management including frequent quality assessments of water sources.Water must be transported in clean, covered containers to avoid exposure to pollutants, stored in sanitized containers at home and, ideally, treated before use to eradicate microorganisms, such as boiling or chlorinating.It is also critical to educate populations about the dangers of unclean drinking water and good hygiene procedures.Regular community participation and hygiene promotion can greatly raise awareness and adherence to clean water practices, lowering the risk of cholera and other waterborne illnesses.
Improving access to medical services and vaccine delivery, particularly in remote regions, as well as expanding vaccine networks, can help patients receive treatments and vaccines promptly.Mapping healthcare and water access against disease data can help identify important needs and predict the impact of climate change and conflicts.Improving logistics by boosting storage at vaccine sites and introducing mobile units with water purification while lowering their exposure to natural and man-made hazards is critical.Integrating Cholera vaccinations into health systems, as well as enhancing outreach and collaborations, can help to increase vaccine uptake and disease monitoring.Health systems in high-risk areas should create emergency plans to deal with anticipated patient surges.Finally, effective epidemic control and the protection of vulnerable populations require close collaboration among nongovernmental organizations (NGOs), local authorities, communities, governments, and professionals (Fig. 1).

Conclusion
Cholera epidemics and inadequate infrastructure in Africa necessitate urgent integrated policies that improve water and sanitation systems and encourage local vaccine manufacture and delivery, such as Ghana's initiative.Improving vaccine distribution, particularly in rural regions, and incorporating it into healthcare systems is critical.Mapping existing water, health, and transportation infrastructure and predicting future infrastructure needs as influenced by climate change and armed conflicts is also important.In addition, community-based collaborations serve as essential for effective disease prevention and treatment.

Fig. 1 |
Fig. 1 | Illustration of the required coordinated efforts to increase vaccine distribution and improve physical infrastructure to reduce cholera outbreaks, along with data showing reported deaths from cholera outbreaks across Africa in 2021 (Data Source: Outworld in Data 15 ).